WHAT WOULD YOU DO? · CASE 01
The case
A 45-year-old man presents to a community emergency clinic with acute central chest pain. BP is 120/70 mmHg, HR 57/min and SpO₂ 97% on room air, without shock or pulmonary oedema. Initial high-sensitivity troponin is elevated. There is no echocardiography or cardiologist on site; a PCI-capable centre is approximately 40 minutes away.
What would you do next?
Which approach best manages the risk while the diagnosis remains uncertain?
- Observe locally for serial troponins before deciding whether transfer is needed.
- Arrange prompt monitored transfer, manage suspected ACS and reassess during preparation.
- Attribute the ECG to ventricular hypertrophy and arrange outpatient echocardiography.
Reveal the answer and reasoning
B — Treat the risk before the diagnosis is complete.
Contact cardiology, transmit the ECG, monitor continuously and repeat the ECG with persistent or changing symptoms. Give aspirin unless contraindicated; assess bleeding risk and dangerous mimics, particularly aortic dissection, before ACS anticoagulation under the receiving-centre protocol.
Why not A or C? Serial troponins remain useful but should not delay indicated transfer. Hypertrophy may explain repolarization changes, but neither the ECG nor one elevated troponin establishes the cause.
Suspected coronary occlusion, refractory pain, haemodynamic or electrical instability demands immediate escalation for invasive assessment.
What happened after transfer?
The echo raised suspicion of apical hypertrophy; one clip cannot establish the complete phenotype or exclude ACS. Coronary angiography reportedly found no obstructive disease; the images were unavailable for independent review. This later information does not invalidate the initial risk-based decision.
Bedside takeaway: A possible structural explanation must not delay assessment of acute chest pain with myocardial injury.
Sources
- Rao SV, et al. 2025 ACC/AHA acute coronary syndromes guideline.
- Pakniyat A. Chest Pain, Positive Troponin, and a Difficult ECG. Original case and media, EM Mastery Academy.
Adapted from the published case. Educational discussion for healthcare professionals; follow local clinical pathways.
